Legal Information

Europeans are becoming more and more interested in cross- border healthcare, but will their insurance foot the bill? Patients often find themselves in a maze of information that is either too vague, too detailed and sometimes flat out wrong. The following article touches on the several key points necessary to understand and pursue healthcare elsewhere in the EU, EEA and Switzerland. The information here is written under the assumption that you are already aware of the various practical risks and obstacles involved in receiving health-care abroad.

Please note that the information here does not apply to patients with private health-insurance.

Medical tourism concept.

Every European citizen is free to seek healthcare elsewhere in the European Union. Funding is unfortunately a different matter alltogether. This article will help you decide if the S2/E112 form route or Directive route is the way to go.

Basic Principles

Rule of thumb: if you have a right to healthcare in your own country, you have an equal right to it elsewhere in Europe. But unfortunately things are not always quite that simple. You may need prior authorization and full reimbursement will not always be a possibility. To further complicate matters, patients can take two different routes towards funding for cross- border healthcare. The older S2/E112 form route (based on the Social Security Regulation) and the Directive route (based on the Crossborder Healthcare Directive). While the two routes are similar, there are some key differences that should be understood as one may be more beneficial to you than the other.

 

The two legal routes differ in several ways, including:

  • The types of treatments and surgeries that are reimbursed.
  • The amount of reimbursement.
  • Whether you need prior authorization.
  • The number and type of care providers from which you can choose.

Generally speaking, the S2/E112 form is more financially advantageous for the patient but significantly more difficult to obtain.

Eligible Countries: Where Can I Go?

You may receive cross-border healthcare in all 28 European member states, as well as in Norway, Iceland, Liechtenstein. Healthcare in Switzerland is only accessible with an S2/E112 form.

Scope of Benefits: Which Medical Treatments Are Eligible?

Untitled Diagram (9)

In order for any treatment abroad to be eligible for funding it must first also be available to you under your own health insurance, regardless of the legal route taken. With an S2/E112 form, the sought treatment must then also be available and approved for funding under the other country’s national health-insurance. This is not the case under the Directive route.

For treatments that do not exist in your home country (and are thus not available to you under your national health-insurance), funding for treatment elsewhere in Europe is only possible under exceptional circumstances.

Click To View Example

A new hip-replacement surgery is available to you under Country A’s national health-insurance. However, you would much rather receive treatment in Country B. The same treatment, while technically available there, is not covered under its national health-insurance.

S2/E112 form route:

Funding for this particular treatment is impossible under the S2/E112 route because it is not covered under Country B’s national health-insurance. Its citizens would have to pay for the treatment themselves, which means you would as well.

The Cross Border Healthcare Directive route:

Reimbursement is possible under the Directive route. The treatment in Country B is identical or equivalent to a treatment that would have been provided to you under your own national health-insurance (Country A).


Prior Authorization: Do I Need It?

One of the biggest limitations of European cross- border healthcare is the requirement of prior authorization. The S2/E112 route always requires prior authorization.

The Directive route however only requires prior authorization if the treatment sought:

  • involves overnight hospital accommodation of the patient in question for at least one night; or
  • requires use of highly specialized and cost-intensive medical infrastructure or medical equipment; or
  • presents a particular risk for the patient or the population; or
  • is provided by a healthcare provider that, on a case-by-case basis, could give rise to serious and specific concerns relating to the quality or safety of the care, with the exception of healthcare which is subject Union legislation ensuring a minimum level of safety and quality throughout the Union.”

These requirements are open to interpretation and said interpretations may very well differ between member states. Generally speaking, the more complex and expensive the procedure, the more likely it is that will you need prior authorization. While the Directive aims to make prior authorization the exception rather than the rule, we suggest you always inquire with your National Contact Point or health-insurance provider to avoid any unpleasant suprises.

Prior Authorization: Undue Delay

Young doctor and virtual screen. Medical tourism concept

Although prior authorization is often required, it may never be refused if an undue delay is present.

You may never (barring some very rare exceptions) be refused prior authorization when the healthcare cannot be provided to you in your home country within a time limit which is medically justifiable. This is better known as the concept of ‘undue delay’Many people assume that just because a treatment is absent in their country, undue delay applies and prior authorization must be granted. This is a common mistake. The treatment sought must be covered by your own national health-insurance (See also: Scope Of Benefits) and there must be an undue delay.

When both conditions are met, your health insurance provider may only refuse authorization under exceptional circumstances (e.g. if the treatment sought would pose a safety hazard to you or the general population).

Additional Requirements

It is likely that any pre-conditions required for accessing healthcare in your own country are also present when seeking healthcare elsewhere in Europe, such as a referral from a GP, consultant or specialist. Always inquire with your health-insurance provider or National Contact Point to ensure that all other pre-conditions have been met before seeking healthcare abroad.

Funding & Reimbursement

An S2/E112 form is generally more beneficial to patients as it treats them as a citizen with health-insurance in the other country. The treatment-costs will then be funded in its entirety, even if the treatment is more expensive than it would have been in their home country. Please refer to the example below for further clarification.

Click To View Example

Hernia surgery costs 5000 euros in Country A, 10.000 euros in Country B. You live in Country A and seek treatment in Country B. For the sake of this example, assume that prior authorization would be granted under both routes.

S2/E112 form route:

Although the procedure is more expensive in Country B, your health-insurance provider will fund the full amount. You are treated as citizen of Country B with national health-insurance, which means funding of the full 10.000 euros.

The Cross Border Healthcare Directive route:

Your health-insurance provider will only reimburse you for the cost of the procedure as it would have been in your home country (A). They will cover 5000 euros, and you will have to pay the remaining 5000 euros yourself.


Up to this point we have assumed that insurance-funds will actually fully reimburse the costs incurred. Naturally, this is not always how it works. Some countries employ what is known as a co-payment charge. They may require its citizens (and consequently other Europeans seeking cross- border healthcare there) to pay for a percentage of the costs. These co-payment charges can be (partly) reimbursed with an S2/E112 form, assuming the total amount reimbursed by your home-insurance fund is less than it would have been, had the treatment been carried out in your own country.

Conversely, any co-payment charges that exist in your own country will also apply if you seek healthcare abroad under the Directive route. See the example below for further clarification.

Click To View Example

Wrist surgery costs 6000 euros in Country A, 7000 euros in Country B. Country B employs a 50% co-payment charge. Country A employs no co-payment charges (full reimbursement). You live in Country A and seek treatment in Country B. For the sake of this example, assume that prior authorization would be granted under both routes.

S2/E112 form route:

You are treated as a citizen of Country B with national health-insurance, so you are also required to pay the co-payment charge (in our example, 50% of the total amount) up-front. This means you will have to pay 3500 euros, while your health insurance provider covers the remaining amount of 3500 euros.

Because your health insurance provider has reimbursed less than it would have had to in your home country (3500 compared to 6000) they will also reimburse you the co-payment charge up to the difference of 2500 euros. Your insurance ultimately pays 6000 euros, the same amount they would have paid had you been treated at home, leaving you with the 1000 euro remainder.

The Cross Border Healthcare Directive route:

Your health-insurance provider will only reimburse you for the cost of the procedure as it would have been in your home country. However, from these 6000 euros, your health-insurance provider may subtract co-payment charges as they exist in your home country.


Reimbursement Of Other Costs

Member states are generally free to decide whether or not they reimburse travel costs, costs of accommodation, translator costs, and so forth. You will have to contact your health-insurance provider or National Contact Point for an answer applicable to your specific situation.

Public Or Private Sector

An S2/E112 form only allows for state-sector treatment. This means that private healthcare providers are excluded. The Directive route allows for both treatment in the private sector as well as the public sector.

Payment Method

In the S2/E112 route costs are dealt with directly between member states. In the majority of cases (barring co-payment charges) patients will not have to pay anything themselves. The form is usually submitted to either the foreign insurance fund or the foreign healthcare provider (who then forwards it to the appropriate institution).

The Directive route employs a cost-reimbursement system. Patients front the costs and seek reimbursement later from their own healthcare service.

Appeal

If you feel prior authorization has been wrongly refused or you have been incorrectly reimbursed then filing an objection with your health insurance fund is the next logical step. European member states are obligated to ensure individual decisions are “properly reasoned and subject to review” so that they can be challenged in judicial proceedings.

If your health insurance fund stands by its original decision, they will inform you about the possibilities of legal recourse. They will specify the relevant Social Court and inform you of any deadlines or further requirements to legally appeal the decision. There are no
litigation costs regardless of outcome.

Liability & Malpractice

Seeking legal recourse for malpractice or liability-issues is always possible, but only under the other country’s laws and regulations.

There’s a National Contact Point for every EU & EEA country. The only country that does not have a NCP is Sweden.

National Contact Points

National Contact Points offer general information to and are obligated to answer questions from patients seeking cross-border healthcare in the EU. You can also ask NCPs other than your own for more specific information on that particular country. Click here for a list of the various NCP’s and how to reach them.

 

 

 

Checklist: Getting Started

  1. Confirm that the healthcare you seek abroad is available to you under your own national health-insurance.
  2. Find out
    • if the healthcare you seek is covered under the other country’s national health-insurance (ask the other country’s National Contact Point).
    • if the chosen foreign healthcare-provider operates in the private or public sector.
    • the costs of the treatment in your own country, the other country and the presence or extent of any co-payment charges.
    • whether you need prior authorization (ask your National Contact Point / health-insurance provider).
    • if there are any additional requirements (ask your National Contact Point / health-insurance provider).
  3. Based on the information you gathered, determine which legal route(s) is/are open to you and which is more beneficial.
  4. If prior authorization is required, follow the application process lined out by your health-insurance provider. If possible, attempt to demonstrate undue delay. If not, focus your efforts on making a compelling argument why cross-border healthcare is justified in your case.

Overview

 E112/S2 form routeDirective Route
SectorPublic onlyPublic + Private
Eligible treatmentsTreatments available under the other country's national health-insuranceTreatments available under your own country's health-insurance
Prior authorizationAlways requiredRequired under certain circumstances
Insurance may always refuse prior authorization, unless undue delay appliesTrueTrue
Costs coveredComplete funding (barring co-payment charges)Reimbursement up to the amount had the treatment been carried out in your home country
Reimbursement of co-payment chargesYes (under certain conditions)No
Method of paymentBetween member-states, no up-front payment from patients required (funding-system)Patients pay up-front and are reimbursed at a later time (reimbursement-system)
Eligible countriesAll EU & EEA countries + SwitzerlandAll EU & EEA countries
Malpractice & LiabilityPossible under country of treatment's laws and regulationsPossible under country of treatment's laws and regulations

Written by Ruben Greidanus, 16-05-2016.


Disclaimer: The information in this article does not in any way constitute legal advice. I give no guarantee regarding the nature, content or accuracy of the information presented here. The information here is a result of personal interpretation and has not been checked or approved by official sources (such as National Contact Points) or attorneys.